The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Tag Archives: Kagan

Teachers’ concerns typically focus on young high reactive(HR) children’s withdrawn or constrained behavior – their preference to watch other children play rather than to join them; their hesitancy in physical games on the playground; their clinging to a parent at drop off; their reluctance to enjoy messy sensory stimulating activities; and their general reluctance to take risks, especially in unfamiliar situations. Often, teachers organize their observations in functional categories such as “separation”, or “peer relationships”. Of course, there can be many reasons why children cling to their parents at drop off or why they do not play with their peers (see below).

In order to identify a HR child, you must listen carefully to the parents. The first clue parents will tell you is that “I was very shy myself.” The second clue is “She is completely different at home – outgoing, active, playful.” The first clue is important, because as we noted in the first posting of this sequence, temperament has an important genetic component. The second is important because HR temperament is primarily about an excitable limbic system. That means that the child is more sensitive to the perception of threat, and the new, the novel, the unpredictable, are threatening. Home is usually familiar and unthreatening. Because of this important factor, I have begun to do home visits when I consult to teachers and parents of children whose teachers have these concerns.

One such child was a 4-yo girl I will call “Jessica”. Her parents described her as loving, sweet, empathic, and smart. She was also “really shy”, and they worried that she was “not comfortable in her skin”. At home, she was confident, free, and creative, but at school she didn’t show these traits. She preferred to play with the teachers instead of the other children. When she went to birthday parties, she retreated into her shell, hiding under her mother’s sweater. Her preschool teachers suggested the consultation because of their concern that she was not engaging with her peers.

“Melinda”, another child, was 3-yo when her teachers expressed concern to her parents that she did not play with her classmates but sat quietly doing activities on her own. Although she looked content, they could not really tell how she was feeling and what she was thinking. On the playground, she liked to swing on one particular swing and got quite upset if that swing happened to be taken by another child.

4-yo “Benjamin” was a quiet, pleasant child whose teachers had to place limits on the time he spent with a girl classmate, Hannah, since she began to look uncomfortable with the degree of physical contact between them, as he insisted on holding her hand and sitting so close to her that he was always touching her. Benjamin explained that he loved Hannah and wanted to marry her, but Hannah complained that she wanted to play with some other friends in addition to Benjamin. In response to the teachers’ limits, Benjamin slowly began to play with other children and has now made a number of friends. Even so, he was often found sitting quietly alone at a table, busy with an activity put out for the children that day.

In the case of each of these children, the teachers balanced their encouragement to take risks in the classroom against their acceptance of the children’s need to “take their time”. As time passed, each child became more comfortable in the classroom. Jessica became animated and playful with the other children. Melinda began to play with her peers and ceded her favorite swing to other children. Benjamin even began to assert himself when another child started to boss him around. It is unclear what precipitated the transformation in each child’s behavior, what allowed these children to be more comfortable in school. In one case the birth of a sibling seemed to introduce possibilities of greater competencies and higher status. In another case my home visit may have been reassuring to the parents. In the third case, the teachers’ more active coaching in social situations combined with acceptance to private school may have been instrumental. Most likely, a combination of these factors played a role. However, the easing of pressure of some sort plus the introduction of new positive possibilities for the future must have figured in all the changes. In any case, we will never know for sure.

Other Reasons for Children to Withdraw:

One important acknowledgement is that there is a large overlap between temperament and sensory processing. Most children with HR temperament have some sensory sensitivities. It is also that children may withdraw if they are sad or depressed. Finally, children with other processing difficulties – for example, auditory processing in which case they have difficulty making sense of verbal communications – may withdraw. In older children, learning disabilities may cause them to “give up”.

Recently I heard an author and editor of The Atlantic magazine, Scott Stossel, talk about his severe anxiety ( Stossel, 2014). What struck me about his story were two things – his description of having had serious problems with anxiety since he was two years old, and also how terrible his anxiety was. He said that the feeling of dread was sometimes so intense that he didn’t think he could go on living. In response to an interviewer asking him what he had found that helped, Scott spoke compellingly about how the first step was accepting the fact that there is no cure, that one has to develop a repertoire of coping skills to deal with the issue and recognize that sometimes you will be OK and other times you suddenly and drastically will not. He even referred to his condition as “temperament”. This rang so true to me.

I pondered on the sweet children I have seen over the years who have had severe anxiety. Some of them have gotten better, and some of them – “stubbornly”! – have not, or at least, are still up and down. Scott Stossel correctly described the problem as a spectrum. All of us have anxiety, but whereas for some it is typical nervousness related to environmental stressors, for others the anxiety is debilitating. I will discuss the treatment of these conditions in another blog posting, since I disagree somewhat with his sense of the limitations of treatment. Right now, I want to talk about the role and the experience of parents with an anxious child.

First of all, I agree with Scott that this problem – barring cases of posttraumatic stress – is largely an issue of temperament. Jerome Kagan and Nancy Snidman talk about how the newly recognized “sensory reactivity disorder” can be seen as a feature of temperament, since both the sensory disorder and also high reactive temperament, have significant heritable features. I don’t say, “inherited”, since we know that the matter isn’t as simple as that. Environmental (and epigenetic) factors have an important role even in the womb, and certainly after birth, when anxious caregivers have a powerful effect on the developing capacity for self-regulation in the infant (Nelson, 2013) (Beebe & Lachmann, 2013). Individual differences tend to be a “blend of temperament and environment” (Snidman, 2011). It appears that the part of the brain that registers threat in response to environmental stimuli – the amygdala – has a lower threshold of reactivity in these children. It is well known that high reactive temperament and the related insufficient development regulatory competencies may complicate a child’s attempts to cope with adverse life circumstances and even everyday transitions (Kagan et al, 2007, Kagan, 1989).

What I would like to focus on here is the effect of an anxious child on his parents. I am not referring to parents just getting anxious when their child is anxious. I am referring to complex patterns of emotional communication that are initiated in infancy and become established and then have a continuing influence on future development – both of the child and of the parents – so that over time, the trajectory of development and associated behaviors become increasingly distorted (Beebe & Lachmann, 2013) . And the people involved don’t even notice it, because they are so intent on staying connected. Many parents of super anxious children tell me that they “walk on eggshells”. What they then explain is that they are afraid of triggering an explosion in their child. But, what I think they really mean is that they are afraid of losing the connection, afraid of losing the child.

Also, they get worn down. When you “lose energy”, as in all living systems (which humans are) you tend to retreat to a simpler but less complex and effective level of functioning. I don’t use the word “regress” because that could imply a global move to a previous level of functioning, whereas when I use the term “retreat” I mean that the idea that the higher level of functioning remains in the individual’s repertoire but he/she does not at that point have enough energy to attain and maintain it. In my practice, I sometimes talk to parents about “being on the front lines” in an attack. If things are not going well and you are in the front lines, you may tend to just shoot rather than – from the more protected position of the generals – plot new strategy.

So from the beginning, when the child cannot sleep or has trouble with feeding, the parents bend over backwards to help the child sleep – such as sleeping with the child – or eat – such as accommodating severely restrictive diets. These parents are trying to protect their child’s survival. However, what they can’t allow themselves to realize at the time is that they are contributing to the distortions that are developing. The child who will explode if you don’t accommodate his demands does not learn to tolerate frustration. The child who “only eats chicken nuggets” doesn’t learn to like other foods.

Before you begin to blame the parents, though, consider what it means to have a child who “will” not eat, “will” not sleep. Sooner or later, you give up and accommodate the child’s demands. That is, unless the parents have support in changing these pernicious patterns.

The support the parents need is in the form of relationships. There are many therapeutic techniques that are recommended, but I am skeptical of all of them that follow manuals and are short term. The children who get better from these techniques – and there are some that do – are on an “easy part of the spectrum”. The parents of children on the hard part of the spectrum need ongoing support to change their responses to their children. They need the support of a long-term therapeutic relationship that encompasses them and their child. I will continue with this subject in a future blog.

Charley Zeanah presented to the group on September 21 and 22. He has been involved in Romania for 14 years. The Romania initiative traces its beginning to a movement started by the 1909 White House Conference on Children that declared its opposition to the institutionalization of dependent and neglected children. Now institutionalization of children whose families cannot take care of them is rare in the U.S., but not in other parts of the world. Romania is a unique story. The research group was invited to study there in the context of a policy debate about what to do with all the children institutionalized by Ceausescu’s government. Under Ceausescu, the official position was that the State could do a better job in raising children than many mothers could, so mothers who were struggling with poverty or other adversities were encouraged to give up their children in the maternity hospital. After several months in the maternity hospital, if the child had no obvious problems, he was transferred to a nursery, where he stayed until 36 months. At that point, if an exam determined him to be normal, the child was sent to a children’s home.

Although there was wide variability in children’s homes, there were some important common features, including many factors working against the establishment of individualized attachment relationships with the caregivers. The children were fed around the table with little or no talking, there was a lot of “free play time” with little support from the caregivers, and aggressive behavior and expressions of distress were often not attended to. Films of this “free play time” revealed painful images of children rocking and spinning.

The study created a model foster home project in which social workers were trained to work closely with the foster families to facilitate attachment and support the foster parents. Interestingly, one of the main effects of this intervention was an increase in IQ of the children in foster families. Also, these children showed greater expression of positive emotion than the institutionalized children within a few months. When assessment was repeated after 42 months in foster families, a community control group had the best attachment to their caregivers, the foster group had medium results, and the institutionalized group had the worst outcome. The children in this last group included a high percentage of withdrawn, inhibited kids with Reactive Attachment Disorder. It is interesting to note that the characteristic “indiscriminate” attachment behavior of RAD persisted even after the group in foster care had formed attachments to their foster families.

Later, when psychopathology was assessed at 54 months, 55% of the children living in institutions had diagnosable psychiatric disorders in contrast with 22% of children in the (control) community group. Both foster care and institutionalized groups had higher levels of emotional disorders (such as anxiety and depression) and behavioral disorders (such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder) than the community group. The improved cognitive outcomes in the foster care children were most significant for children placed in foster care before 24 months. Similar sensitive periods were also found for the development of language, attachment, and indiscriminate behavior. An important finding was that secure attachment at 42 months predicted psychopathological outcome at 54 months. Interestingly, there was a big gender difference, with most of the securely attached children at 42 months being girls and most of the children with psychiatric symptoms at 54 months being boys.

In conclusion, the research group found that children raised in institutions have compromised development across almost all domains, that attachment status moderates many aspects of psychopathology, and that the socio-emotional effect is more profound than the cognitive effect. When you place these children in good foster homes, you get attachment recovery and some – but not all – recovery from psychopathology. The research group strongly recommends intervening in abusive and neglectful caregiving situations as early as possible. More specifically, they propose removing children from institutions and placing them in foster homes.

I noted that this was a beautiful presentation of a study of monumental importance in child development and child psychiatry. The study demonstrates the power of the caregiving relationship to influence development. I pointed out, though, that the Romanian orphanages represent – as Dr. Zeanah explained – a rather unique and extreme caregiving situation, and that there is a problem in that is that this study of Romanian orphanages is being used by some international agencies to promote a one size fits all approach to the problem and laws such as LEPINA in El Salvador that require immediate reunification of institutionalized children with their biological families, with little or no support for their severely disadvantaged and dysfunctional families in the community.

Ed Tronick quoted the “old literature “– the first edition of Jerome Kagan’s book on child development that included accounts of children raised in institutions after WWII. These children did relatively well. How can we explain that? One possible reason is that there was a commitment to these children because of something terrible, morally bad that had been done, enhancing the caregivers’ desire to do something for them. Dr. Zeanah talked about the meaning of the children to the caregivers. In the case of Romanian orphanages, the society’s negative attitudes towards the Roma, who make up of 30% of children in orphanages, though they comprise only 6-9% of the population, may affect the caregivers’ commitment to the children.

Dr. Zeahah said that their group is interested in individual differences in response to institutionalization among the children. He noted that there may be a relationship between certain genotypes and indiscriminate behavior. They are looking at alleles that are very sensitive to experience and those that seem impervious. In that case, if you have the impervious alleles you fare well no matter what the environment and if you have the sensitive alleles you may struggle in an average expectable environment. Readers of the blog will recognize the “orchids versus dandelions” metaphor.

Apropos these last comments, I had a number of thoughts. First, I would underscore the importance of the meaning of the child to the caregivers. For example, a religious or spiritual mission to minister to children in need may allow caregivers to see the child as deserving of loving care and to recognize the unique value of each child, while also sustaining the caregiver through the frustrations and disappointments involved in their tasks. For example, the message that each child is precious to Jesus – no matter what he looks like or how much he achieves – is a powerful message indeed. It is also important to remember the orchids and dandelions story. This story emphasizes the individual characteristics of each child, including the ability – innate or acquired – to take in the good in their environment and make it part of themselves. These thoughts remind us of the complexity of development and of how important it is to continue to search for a repertoire of solutions so that we can find a unique approach to each unique challenge.

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.